Imagine you underwent a surgery, and despite poor results, you ended up paying more than another patient who had a successful outcome. Unbelievably, this can happen under Japan’s current medical remuneration system.
This almost comedic scenario occurs because Japan’s current remuneration system is centered around the process of treatment rather than the outcome. In a process-centered remuneration system, compensation is generated for the medical procedures performed, regardless of the treatment results. This means that physicians are paid whether or not the patient recovers. In fact, in some cases, greater compensation is awarded for unsuccessful treatments. This system tends to be more physician-centric, and cannot be considered patient-centric. On the opposite spectrum lies an outcome-centered remuneration system.
On the other hand, the current process-centered remuneration system does not inherently motivate physicians to improve their surgical skills. Since my early career, I have been committed to mastering eye surgery, driven by a pure desire for improvement, an ambition to be respected for my skills, and a wish to receive more patient referrals. Despite now possessing advanced surgical skills and consistently delivering positive outcomes, I find it frustrating that striving for high-quality surgeries for the benefit of patients doesn’t translate into equivalent remuneration. Worse, I might even earn less than physicians who achieve poorer surgical results. This mix of resignation and wry amusement underscores a pressing issue that needs to be addressed for future generations of physicians and patients.
Medical remuneration systems should be designed not only to be patient-centric but also to foster physician motivation. With this in mind, let’s explore the current process-centered remuneration system, and consider what solutions might be feasible, incorporating an outcome-centered approach.
What oddities can arise from a process-centered remuneration system?
Consider the case where physicians with a high rate of complications in surgery end up with a higher remuneration. Surprising as it may seem, this is indeed the reality. Moreover, the process-centered medical remuneration system, while ideally premised on physicians striving for the best patient outcomes, can lead to quite the opposite if physicians lose sight of their medical ethics and chase profits instead. Let’s look at some examples to illustrate this. For context, it’s important to understand that in Japan, the medical remuneration points are calculated as: remuneration points × 10 = remuneration (in yen).
Cataract Surgery
Cataracts, a condition where the lens of the eye becomes cloudy leading to a decrease in vision, can be treated with cataract surgery. In Japan, the standard cataract surgery, which involves the removal of the cloudy lens using a technique called phacoemulsification (breaking up and suctioning out the lens contents with ultrasound) and the insertion of an intraocular lens, is assigned a remuneration of 12,100 points (121,000 yen). However, if a complication like capsule rupture occurs during surgery, an additional procedure, vitrectomy (removal of the vitreous body behind the lens), which is worth 15,560 points, is performed. Consequently, the total remuneration for a cataract surgery with capsule rupture becomes significantly higher, often more than double, compared to a successful cataract surgery without the complication.
Capsule rupture is a complication that occurs in about one in every hundred cataract surgeries, where the posterior capsule that supports the intraocular lens tears. This complication makes the surgical procedure more challenging, leading to additional surgical steps and extended operation time. It often results in delayed vision improvement post-surgery, increases the risk of developing postoperative complications, including endophthalmitis (an infection inside the eye), and may lead to suboptimal refractive outcomes and incomplete astigmatism correction. For patients, it offers no benefits, only drawbacks.
The rate of capsule rupture tends to be lower in skilled and careful surgeons, while inexperienced or speed-focused surgeons have a higher tendency for this complication. When the capsule ruptures, the vitreous body, a fibrous gel-like tissue located behind it, protrudes forward, causing several postoperative complications, hence the need for its careful removal through vitrectomy. In a process-centered remuneration system, ironically, the occurrence of a complication like capsule rupture leads to more procedures and consequently, higher remuneration.
Retinal Detachment Surgery
Retinal detachment, a condition where the retina detaches from its underlying layer, cutting off its supply of oxygen and nutrients, is an extremely high-risk situation for vision loss. It requires semi-emergency surgery. The success of retinal detachment surgery heavily depends on the surgeon’s skill, more so than in cataract surgery. Inexperienced surgeons increase the likelihood of the retina becoming redetached, necessitating additional surgeries. If the retina isn’t reattached, the risk of blindness remains, making multiple surgeries necessary until successful. However, repeating surgeries makes the retina more prone to fibrosis, making it harder to treat. Therefore, successfully reattaching the retina in the first surgery is crucial. Despite variations in difficulty, the key concept for any case is to completely remove the vitreous traction on the retinal tear. This requires a highly skilled surgeon spending a considerable amount of time, typically about an hour, to perform the necessary vitreous shaving.
The remuneration for a standard retinal detachment surgery varies based on the technique used, but for scleral buckling, it’s 34,940 points, and for vitrectomy under the microscope, it’s 38,950 points. Recently, the latter technique has become more common. A skilled vitreous surgeon who successfully reattaches the retina in one hour earns 38,950 points. In contrast, an inexperienced surgeon who takes an hour but results in the retina redetaching leads to repeated surgeries, each being charged as a separate vitrectomy at 38,950 points. Thus, the remuneration doubles or even triples, depending on the number of surgeries required to achieve complete recovery. For instance, a tripled remuneration would be 38,950 points × 3 = 116,850 points. In this way, a process-centered remuneration system paradoxically results in higher remuneration for a surgeon who cannot successfully reattach the retina in one operation, as the process of surgery increases.
Even worse scenarios are possible. Consider a physician who completes a retinal detachment surgery in just 15 minutes. Naturally, such a short duration is inadequate for proper vitreous shaving, leading to redetachment. The physician then repeats these 15-minute surgeries each time the retina redetaches. I have often been sought for a second opinion by patients who underwent surgery up to five times without success. From the patient’s perspective, enduring multiple surgeries not only results in significant emotional and physical strain but also in financial burden, all without restoring their vision. Astonishingly, despite the lack of successful outcomes, the physician profits significantly, with total remuneration potentially reaching 38,950 points × 5 = 194,750 points (1,947,500 yen), a concerning reality under the public health insurance remuneration system. This situation underscores the critical need for a remuneration system that prioritizes patient outcomes over the number of performed procedures, aligning the incentives of healthcare providers with the well-being of patients.
Why a Process-Centered Remuneration System Doesn’t Directly Link to Enhancing Surgical Skills
In a process-centered remuneration system, the focus is not on the quality or outcome of surgery, but rather on the quantity of procedures performed. This system tends to encourage an increase in the number of surgeries rather than improving surgical skills.
Of course, the motivation to improve surgical skills can still exist within a process-centered remuneration framework. For instance, young doctors affiliated with university hospitals are in a phase of honing their skills, driven by a desire for self-improvement and recognition from their superiors. The competitive spirit, a crucial motivator across all fields and eras, plays a significant role here.
Once past the training phase and working independently, surgeons who have refined their skills and achieved good outcomes can enhance their reputation and attract more patients seeking surgery. Even within a process-centered remuneration system, where the number of surgeries correlates with profit rather than surgical outcomes, there’s motivation to improve surgical skills to increase surgery numbers. However, the drive to enhance surgical skills becomes diluted compared to an outcome-centered remuneration system, which directly rewards better patient outcomes. Part of the reason for this dilution in motivation is the advent of alternative patient attraction methods available to doctors, such as marketing and especially online marketing strategies (including well-designed websites, social media, and online advertising), which can overshadow the imperative to improve surgical techniques. The complexities and implications of a digital society on healthcare will be explored in a separate blog.
The Need for a Remuneration System That Enhances the Quality of Surgery for Each Patient
The process-centered remuneration system inherently encourages shorter surgeries and a higher volume of cases, leading to profitability. Imagine a scenario where a surgeon accelerates the speed of surgeries within a given time to perform more procedures. Naturally, this could result in less precise operations and, in the case of cataract surgery, might lead to a higher rate of complications, such as capsule rupture, or the neglect of labor-intensive meticulous astigmatism correction. On the other hand, patients universally prefer not just speedy but high-quality, long-term satisfactory surgeries—essentially, superior outcomes. Therefore, it’s evident that the process-centered remuneration system, by focusing on quantity over quality, inherently disadvantages patient-centered medical care. In today’s advanced medical landscape, it’s time to evolve the remuneration system to prioritize patient-centered care, aligning with the belief that healthcare must progress towards rewarding better patient outcomes.
Can We Leap Towards a Patient-Centric Remuneration System by Incorporating the Concept of Outcomes?
If what patients seek from surgery is a superior outcome, then an outcome-centered remuneration system, where compensation varies based on the quality of outcomes, emerges as a viable option. Such a system would undoubtedly enhance physicians’ motivation to improve their surgical skills. While an outcome-centered remuneration system has its pros and cons, the discussions in this blog highlight a glaring issue with the process-driven remuneration system: it leaves patients behind. Although transitioning entirely to an outcome-based system presents challenges, integrating outcome-focused approaches at key points could shift towards a more patient-centric remuneration model.
Proposed Modifications to the Remuneration System for Cataract and Retinal Detachment Surgeries
Let’s specifically look at proposed changes for cataract and retinal detachment surgeries as examples.
Patient-Centric Outcome-Focused Remuneration Ideas for Cataract Surgery
Considering capsule rupture (a complication of cataract surgery), it’s a condition that won’t disappear even with the utmost care during surgery. High difficulty levels can cause it, but surgeons with advanced skills are less likely to experience it, even in challenging situations, indicating the significant impact of a surgeon’s skill. Therefore, there should be an incentive within the remuneration system for surgeons to reduce capsule rupture rates. Currently, the process-centered system paradoxically rewards surgeries that result in capsule rupture with higher compensation.
Incentive-Based Approach
For surgeries completed without capsule rupture, adding a 20% bonus to the surgical points could be one approach. However, given that the rate of capsule rupture is around 1%, not causing it is the norm, and this method might simply inflate overall surgical compensation.
Penalty-Based Approach
Conversely, applying a penalty, such as a 20% reduction in compensation for surgeries resulting in capsule rupture, could be considered. Or, not allowing additional compensation for needed procedures, such as vitrectomy (15,560 points), following a rupture, which could pose a more significant penalty due to the costs of disposable instruments and extended surgery time.
Capsule Rupture Rate-Linked Remuneration
Mandating annual reports on capsule rupture rates and adjusting compensation based on these rates could align more closely with the goal of enhancing surgical outcomes. For example, clinics with an annual capsule rupture rate below 0.5% could have their remuneration set at 13,310 points (12,100 points × 1.1), those with a rate from 0.5% to less than 1.5% would receive the standard 12,100 points, and clinics with a rate of 1.5% or higher would see their remuneration reduced to 10,890 points (12,100 points × 0.9). This method acknowledges that, despite high skill levels, challenging cases with a much higher risk of rupture exist and should be considered separately in the evaluation.
Incorporating Surgical Difficulty into Remuneration for Retinal Detachment: A Proposal for Patient-Centric Outcome Enhancement
Remuneration Reflecting Difficulty
Rhegmatogenous retinal detachment presents a significant variation in difficulty due to factors such as the cause, number and location of retinal tears, extent and height of retinal detachment, vitreous condition, and patient age. Some cases are easily resolved with a single surgery regardless of the surgeon, while others may not be successfully treated without the expertise of a skilled surgeon. The process-centered remuneration system fails to account for the difficulty of rhegmatogenous retinal detachment, posing a challenge. Initially, grading the difficulty and reflecting it in the remuneration would be necessary. Building on this, a mechanism that incorporates the outcomes of rhegmatogenous retinal detachment surgeries into the remuneration system would be beneficial.
The ultimate goal for rhegmatogenous retinal detachment treatment is achieving a complete cure (reattachment) in the first attempt, referred to as the initial reattachment rate. Generally, facilities like universities where multiple surgeons perform retinal detachment surgeries report an initial reattachment rate around 90%. There are facilities with higher and lower rates. Naturally, higher difficulty cases have lower initial reattachment rates. Therefore, it’s crucial to consider that facilities attracting high-difficulty cases due to their surgical expertise might inherently decrease initial reattachment rates
Incentive System
One approach could be to add a 20% bonus for surgeries resulting in initial reattachment. However, similar to the capsule rupture scenario in cataract surgeries, since the initial reattachment rate is around 90%, this method would essentially increase the overall remuneration.
Penalty System
Another consideration could be reducing the remuneration for any subsequent surgeries that are necessary due to the failure of achieving reattachment on the first attempt. The extent of the reduction needs discussion, but hypothetically, reducing it to cover just the cost of disposable instruments and staff for a second surgery could effectively eliminate profit, creating a strong incentive to ensure reattachment on the first attempt. It’s important to note that patients may seek a second surgery at a different clinic. In such cases, even if it’s the patient’s second surgery, the subsequent facility should treat it as the first surgery for that patient.
Initial Reattachment Rate-Linked Remuneration System
Mandating a report on the initial reattachment rate and the difficulty of retinal detachment cases over the past year, and then ranking surgeons or clinics accordingly to adjust their remuneration rates could be another strategy. Unlike cataract surgery, considering the difficulty of cases is more complex, leading to a more nuanced approach. Designing the system so that higher initial reattachment rates result in greater total remuneration would undoubtedly boost surgeons’ motivation.
Maintaining a Win-Win Relationship Between Doctors and Patients Through Sustainable Remuneration System Design
Among the ideas presented, the concept of linking surgical outcomes to remuneration seems most fitting, both for cataract and retinal detachment surgeries. Whether this is the optimal solution is up for debate. Remuneration systems built solely from a healthcare economy perspective can lead to unintended consequences. It’s essential to incorporate mechanisms that encourage surgeons to enhance their skills and pursue high-quality surgeries, as the essence of surgery lies in improving outcomes through the refinement of surgical techniques, which directly benefits patients. Relying solely on the medical ethics and ambition of doctors is not sufficient. Designing a sustainable remuneration system that maintains this win-win relationship between doctors and patients is of utmost importance.
Among the ideas presented, the concept of linking surgical outcomes to remuneration seems most fitting, both for cataract and retinal detachment surgeries. Whether this is the optimal solution is up for debate. Creating remuneration systems from a healthcare economy perspective alone can lead to unintended consequences. It’s crucial to include mechanisms that motivate surgeons to refine their skills and strive for high-quality surgeries, as the essence of surgery is to improve outcomes through the refinement of surgical techniques, which directly benefits patients. Relying solely on the medical ethics and ambition of doctors to enhance their surgical skills is not sufficient. Designing a sustainable remuneration system that preserves this win-win relationship between doctors and patients is paramount.